Reviews & Analysis

The impact of biologic therapy for rheumatoid arthritis on quality of life has clear relevance to studies of the cost-effectiveness of these agents. As discussed in this Viewpoint, however, several deficiencies in current economic evaluations need to be overcome in order to enhance the utility of such research.

Although rituximab specifically binds to CD20 on B cells, it also has efficacy in the treatment of autoimmune diseases that are predominantly mediated by T helper cells. In this Viewpoint, Dr Datta proposes a novel hypothesis to explain this: the association of the pathogenic autoreactive T cells with anti-CD20 opsonized B cells might in fact make rituximab specific for autoreactive T cells.

A considerable increase in the risk of developing cardiovascular disease is conveyed not only by inflammation, but also by the use of glucocorticoids to treat inflammation. In this Viewpoint, the authors discuss the challenge of balancing the relative benefits and hazards of glucocorticoid treatment for inflammatory diseases, as well as the tantalizing prospect of identifying subgroups of the population at risk for cardiovascular disease.

Updated guidance from the UK National Institute for Health and Clinical Excellence on the use of tumor necrosis factor (TNF) antagonists for rheumatoid arthritis recommends that patients who do not respond to initial anti-TNF therapy should not switch to another TNF inhibitor. In this Viewpoint, the authors discuss the rationale and controversies surrounding this recommendation.

Scleroderma-like disorders, which often have marked clinical overlap with scleroderma, can present a diagnostic challenge. In this Viewpoint, the author describes key clinical and laboratory features that can aid early diagnosis and prompt appropriate management.

In light of the impressive efficacy of tumor necrosis factor blockers in the treatment of ankylosing spondylitis, particularly in patients with short disease duration, defining outcome parameters to monitor the structural damage of the disease has become more pertinent. In this Viewpoint the authors explore the relevance of osteoproliferation amongst other outcome parameters.

In this Viewpoint, Drs Doria and Briani highlight recent advances in efforts to improve the long-term prognosis of patients with systemic lupus erythematosus. The strategies discussed aim to prevent both the occurrence of the disease and its complications.

Hypermobility-related disorders are frequently encountered in clinical practice, but are too often dismissed as trivial. In this Viewpoint, Prof. Grahame discusses why the current perception of these disorders is inadequate, and highlights recent advances in the field as well as challenges and opportunities for future research and therapy.

Guidelines for access to biologic therapies vary considerably between different nations. In this Viewpoint, Drs Deighton and Hyrich discuss the pros and cons of current guidelines for anti-tumor necrosis factor therapy in patients with rheumatoid arthritis, and recommend a number of elements that should be included in future guidelines.

Although useful in clinical trials, current measures of RA activity have important limitations when used in clinical practice. In this Viewpoint, Drs Wolfe and Michaud discuss the limitations of these activity scales and indices, and recommend that clinicians use these measures in combination with longitudinal data and additional non-questionnaire information about the patient.

Central nervous system vasculitis can cause a wide spectrum of neurological deficits in children. In this Viewpoint, Drs Cantez and Benseler provide an overview of the field and highlight for rheumatologists the importance of recognizing and appropriately treating this disease.

In rheumatoid arthritis, bone involvement presents as generalized osteoporosis, periarticular osteoporosis and erosions. Prof. Haugeberg discusses evidence for all three features resulting from increased activation of the osteoclast, and suggests that potent anti-inflammatory treatment, or direct inhibition of the osteoclast, might protect against all of these types of bone damage seen in patients with rheumatoid arthritis.

Noncommercial, investigator-initiated trials are an essential part of clinical research. In this Viewpoint, the author describes the burden of current legislation on investigator-initiated trials and explores possible solutions.

Emerging data implicate a novel subset of CD4⁺ T cells, termed T_H17 cells, in the pathogenesis of several autoimmune diseases. In this Viewpoint article, the authors discuss the role of T_H17 cells in systemic lupus erythematosus and discuss their potential as a therapeutic target.

Systematic reviews, although they can highlight important findings in the literature, often raise even more questions. In this Viewpoint, Prof Smolen and Prof Aletaha discuss approaches to comprehensive reviews in general, and to those involving rheumatoid arthritis in particular, from the clinical trialist's point of view.

Even well-performed systematic reviews do not necessarily provide informative guidance for patient care. In this Viewpoint, Professor Pincus and colleagues argue that evidence from observational research and clinical experience is needed to supplement clinical trials to improve health and outcomes for people with rheumatoid arthritis.

The author of this Viewpoint argues that there is currently insufficient evidence to guide the choice of therapy in rheumatoid arthritis, and highlights the need for large, simple, pragmatic trials designed to determine the best way to treat early or established rheumatoid arthritis, how aggressively to approach comorbidity, and how patients should be monitored.

In the treatment of rheumatoid arthritis, where can clinicians find the information to help them decide which drugs to use in what combination and when to use them? In this Viewpoint, the author argues that there is a need to look beyond short-term efficacy studies, and highlights several unanswered questions still to be addressed.

The biology of disc degeneration is complex. Some remarkable advances in molecular and cellular biology have recently been achieved in this rapidly evolving field and biological technologies for intervertebral disc repair are currently being developed. In this Viewpoint, Dr Peng discusses the problems that need to be resolved before these technologies can advance from the laboratory to clinical trials.

Most patients with chronic conditions, such as osteoarthritis, only have contact with healthcare professionals for a few hours over the course of a year. Good self-management programs are, therefore, critical for patients to cope with their conditions on a daily basis. Drs Osborne, Jordan and Rogers discuss the importance of engaging patients, clinicians and policymakers in the development and implementation of self-management programs.